04120065 CI TY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION �
Bwl.Dwc ADDRESS: K & M DEVELOPMENT INC PERMTN 04120065
WNGT=U?q]3TJS A-V
R' AM : PERMIT ISSUE DATE
E; SANITARY OL NO.
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
en' LICENSED CONTRACTOR'S DECLARATION
0o Job Descri tion
WU C 1 hereby affirm that 1 am licensed under provisions of Chapter 9(commencing P
U wiNto
Section 7000)of Division 3 of NC Businessand Professions Code andmylicenmi.
in full forte anJ cffecL
�qz Leenuclms tie. DEMO (E) HOUSE
g— Dau O Contrm or ayL ASN
'� ARCHITECTS DECLARA OTTNr
1 understand my plans shall be used as public records
JaU
u G Limnssd Professional
X05 OWNER-BUILDER DECLARATION 't?q
.�<� 1 hereby affirm dial I am exempt from me Contractors License Law for the
pO following reason.(Section]rU I.S.Business and Professions Code:Any city or county V
If m which requires a pomdt In construct,alter,Improve,dmnOlish,lir repair my Structure
poor u its issuance.also routines the applicant for such permit to file a signed suument
< shat he is licensed pursuant to Me provisions of McContrmmrs,Liemse aw(Chapmr9 Sq. FL Floor Area Valu tion
(commencing with sodium TOM)of Division 7 of dic Business and Professions Code)or
u $ that he is exempt thclefrom and Ne basis for die alleged caemplion.Any violation of
Section]031.5 by any applicant for a permit subjects Ne applicant to a civil penalty of
no,more man fin hundred doll...MIDI). 3 B�<�4�117f�erO 0 Occupancy Type
I,as owner Of the Property or my employees with ago p their sole compensation,
will do me work,and Ne someone is not intended or offered for sale(Sec.7Ga4,Business
and Profcssiom Code:The Comucmrs Lime law docs oat apply to an all of Required Inspections
property who builds or improves thereon,and who doesauch work himself or Borough his
awn employees,provided that such improsemcnts are not intended moaned foraale.If.
however.me building or improvement is said within one year of completion.me owner.
builder will bare the burden of proving that he did not build or improve for Pon=of
.talc.).
❑1,as owner of die property,am exclusively contracting with licensed comracmrs to
comvuct the pmject(Sec.7034,Business and Profession Code:)The Contractors Li.
come law does not apply in an owner of progeny who builds or improves thereon,and
who contracts for such projects with a contractor(s)licenssd pursuant to the Contractor's
License law.
❑1 am exempt under Sec. .R&P C for Bois reran
Owner Dau
137MWORKER'S COMPENSATION DECLARATION
1 hereby afllrm under penalty of perjury,one of me following declantiom;
ham and will maintain a Certificate of Consent to aelbinsure for Worker's Compen-
n,ax provided for by Section 7]00 of me lobar Code.for me perlormamee of me
for which this Permit is issued.
have and will maintain Worker's Compensation Imuran¢,as required by Section
of die labor Code,for Me performance of Ne work for which this permit is issued.
er i Compensation lnaunntt carticr of cy Noy��3er'� .•✓
CERTIFIC OMPE EMfN1ON FROM WORKERS'
COMPENSATION INSURANCE ,
(Thu section head not Ic completed lithe Permit is for one hundred dollars(2100)
or less)
1 certify that in Ne penformanc,of the work for which Bois permit is issued,1 shall or
employ any Person in any man gm acre subject o me workers'CorNmaunn
Laws of California.Dau -
Appli
NOT( afar ing mu C talc of Excmp'on,you should
become subject u me Wohe"s nvuon p isions or die V ode,you muse '
.J O rprthwith comply with such provision or this itnhall M dcc mated.
'Z ^" CONSTRUCTION LENDING AGENCY
[— � I hereby affirm that there is a conswetion lending agency rat me Performance of
Me work for which this permit is issued(Sec.7097.Civ.C.)
lender's Name
z finder's Address
U 1 certify Out 1 ban rod this application and sou mat die above information is
corms 1 agree to comply with all city and county on inames and sum laws relating to
pU building conswclion,and hereby anthorre repmacnutins or this city to enter upon me
r W .hove-mentioned progeny Tor impaction proposal.
0. to save,
ndcrunify ad
less Me City of Cupertino
ainat
(r ,,, liabilities,judgments,costs aandcxpcmes which may in any ay game against said City
U Z in immemucnce of the granting of Bois permiL
.. APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS. ' S,
Re-roofs
Signature of Ua / Dam
OUS MATERIALS DISCLOSU E Type of Roof
Willdieapplinm or tiding occupant more or handle hnasdom material
as dcrmcd by me Cupertino Municipal Code,Chapter 9.13,and die Health and Safety
Code,semen zss7z(a)+� All roofs shall be inspected prior to any roofing material being installed.
❑Yes No
will William.
lir future building o tpant t equipment or devices whim If a roof is installed without first obtaining an inspection,I agree to remove
it ha,ardnus air conuminans cfihm0 by the Bay Arca Air Quality Management all new materials for inspection.
District,
❑Yes No
1 have mail die hanrdous materials requirements under Chapmr6.95 orthe Califor
ria Health&Safety Codc,Sectors 255115,25577 and25534.1 understand del if the wildirg
does not currently ban a mnam,that it is my hespomihility to nouly the necupant lir me
requirements which most be or to i.e.or.ccri fDFXuPami Signature of Applicant Date
Owrerm.0 nr,odx,, Dalc All roof coverings to be Class rB"or better